webInsure Registration

Payee Information

Do you want payment for your individual sales to be made out to your agency or to you as an independent agent? Must match how you are set up with WebInsure.

Independent Agency

Agency Information

Name and Tax ID must match what is on file with the IRS.

Agency Legal Name:

Agency Federal Tax ID (TIN):

DBA ( if applicable ):

Agency Address:

Agency City

Agency State:

Agency Zip Code:

Agency National Producer ID # (NPN):

Agency Contact Name:

Agency Contact Phone (xxx-xxx-xxxx):

Agency Contact Email Address:

Selling Agent/Licensed Producer Information

Name and Tax ID must match what is on file with the IRS.

Licensed Producer Name:

Producer Federal Tax ID (TIN):

DBA ( if applicable ):

Licensed Producer Phone (xxx-xxx-xxxx):

E-mail Address:

Social Security Number (SSN)

Same as Agency address

Business Address:

Business City:

Business State:

Business Zip Code:

Same as Business address

Licensed Producer Residence Address

Licensed Producer Residence City

Licensed Producer Residence State

Licensed Producer Residence Zip Code

Licensed Producer National Producer Identification # (NPN)

Licensed Producer Birth Date (MM/DD/YYYY)

State & Licenses

Please provide all state license information where you will be doing business
To register for more than 10 states, enter the first 10 here and submit. Then email ASCA@vsp.com with your additional states and license numbers.

State:

State

Licensed Producer's License #

Agency License #:

State:

State

Licensed Producer's License #

Agency License #:

Delete

State:

State

Licensed Producer's License #

Agency License #:

Delete

State:

State

Licensed Producer's License #

Agency License #:

Delete

State:

State

Licensed Producer's License #

Agency License #:

Delete

State:

State

Licensed Producer's License #

Agency License #:

Delete

State:

State

Licensed Producer's License #

Agency License #:

Delete

State:

State

Licensed Producer's License #

Agency License #:

Delete

State:

State

Licensed Producer's License #

Agency License #:

Delete

State:

State

Licensed Producer's License #

Agency License #:

Delete

Add commission address Same as Business address Same as Residence address

Same as Agency address

Commission Address

Commission City

Commission State

Commission Zip Code

W-9 Information

Name and SSN/TIN must match what is on file with the IRS in order to complete registration:

Under penalties of perjury, I certify that:

The number shown on this electronic form is my correct Taxpayer Identification Number (or I am waiting for a number to be issued to me), and
I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and
I am a U.S. citizen (including a U.S. resident alien).

By checking this box, I confirm that the information above is correct.

Agent Agreements

Please review the Agent Agreements.

I certify that I have read and agree to the terms of the Agent Agreements.

Submit

VSP Certified Platform Partners Registration

Payee Information

Agency Information

Selling Agent/Licensed Producer Information

W-9 Information

Agent Agreements